Provider Demographics
NPI:1134210347
Name:FITZGERALD, BRYAN T (DO)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:T
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5664 STONE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6001
Mailing Address - Country:US
Mailing Address - Phone:937-435-7445
Mailing Address - Fax:937-433-7475
Practice Address - Street 1:5664 STONE LAKE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-6001
Practice Address - Country:US
Practice Address - Phone:937-435-7445
Practice Address - Fax:937-433-7475
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-002637207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHFI0797582Medicare ID - Type Unspecified
OHC03554Medicare UPIN
OH0491561Medicaid